Cysts of the Jaws

Dr. Rima Safadi

Definition A pathologic cavity lined wholly or in part by epithelium having fluid or semisolid content not created by pus accumulation

Cysts of the Jaws

Classification according to lining

epithelium origin

Odontogenic Non Odontogenic

Odontogenic Cysts:
1. Dental lamina:
Odontogenic keratocyst, lateral periodontal cyst

Origin

1. Enamel Organ:
Dentigerous cyst

3. Hertwig

epithelial root sheath:

Radicular cyst

Odontogenic Cysts
Inflammatory Radicular cyst Paradental cyst

Developmental
Dentigerous cyst Eruption cyst Odontogenic keratocyst Primordial cyst Glandular odontogenic cyst Lateral periodontal cyst Calcifying odontogenic cyst

Non-odontogenic Cysts
Developmental

Pseudocysts

Nasopalatine duct cyst Nasolabial

Simple bone cyst Stafne bone defect Aneurysmal bone cyst

Radicular cyst

Apical Lateral Residual

Radicular Cyst (Periapical Cyst)

Apical:

75% of all radicular cysts Always with apices of non vital teeth Small: symptom less Large: expansion of bone
5 mm/year Egg-shell crackling Submucosal swelling

Radicular Cyst Enlargement

Oral Pathology, 4th edition, Soams and Southam

Radicular Cyst (Periapical Cyst)

Apical:

Pain is rare
Except if there is acute exacerbations

Radioghraphically:
round radiolucency at the root apex with or without radioopaque margin 40% of all PA radiolucencies are cystic

Radicular Cyst (Periapical Cyst)

Residual:

Only 20% of all radicular cysts Remains after tooth extraction

Lateral:

Very uncommon Extension along lateral root canals

Radicular cyst
Pathogenesis: Proliferation of epithelial rests of Malassez within chronic periapical granuloma
Not all granulomas progress to cysts

Stimulus:
controversial,
Persistence of chronic inf. stimuli bacterial endotoxins, cytokines, growth factors

Mechanism of cyst formation:

Degeneration of the central portion of epithelial mass

Epithelium is avascular Critical size

OR Degeneration of granulation tissue

Isolation of G. T by strands of epithelium Release of toxic products

Radicular Cyst
Microscopic Features
Lined by non-keratinized stratified squamous epithelium Fibrous tissue capsule, Richly vascular Inflammatory infiltrate May surround root apex (pocket cyst), or separated by tissue capsule (more common) Metaplasia of cyst lining:

Mucous cells Ciliated cell

10% shows Rushton bodies: epithelial product? Cholesterol clefts: dead epithelial cells and RBCs

Newly formed cyst

Established cysts

Rushton bodies

Cholesterol clefts

Pocket

Cyst

Oral Pathology, 4th edition, Soams and Southam

Cyst contents:

Degenerating cells Serum proteins Hypertonic compared to serum: Protein concentration: 5-11g/dl
Higher levels of Ig

Water and electrolytes Cholesterol crystals

Cyst expansion

Expand equally in all directions

Controlled by rate of bone resorption

Bone resorption
activation of osteoclasts by PG and cytokines degradation of bone matrix by enzymes collagenase

stimulated by IL 1 and IL6

Osmotic gradient. Semipermeable membrane (cyst wall)

Hydrostatic pressure Seperation of cyst lumen from lymphatic drainage

Radicular Cyst apical

Color Atlas of Clinical Oral Pathology Neville, Damm and White, 2nd edition

Lateral Radicular Cyst

Color Atlas of Clinical Oral Pathology Neville, Damm and White, 2nd edition

Residual Cyst

Oral Pathology, 4th edition, Soams and Southam

Residual Cyst

Radicular Cyst (Periapical Cyst)

Management and Prognosis
Treatment of the involved tooth Surgical enucleation or curettage of the cyst Little tendency for recurrence or neoplastic transformation

Questions

Developmental Odontogenic Cysts

The most common developmental odontogenic cyst accounts for 25% of all jaw cysts
Associated with unerupted teeth Attached to cementoenamel junction Central type Lateral type

Dentigerous Cyst (Follicular Cyst)

Dentigerous Cyst (Follicular Cyst)

Color Atlas of Clinical Oral pathology Neville, Damm and White, 2nd edition

Dentigerous cyst

Origin: reduced enamel epithelium between the follicle and the tooth crown enlarges by accumulation of fluid between proliferating, reduced enamel epithelium and crown

Pathogenesis

Dentigerous Cyst (Follicular Cyst)

1. Proliferation of outer layer of reduced enamel epithelium and cyst formation OR 2. Compression of the follicle fluid exudate

separation of the reduced enamel epithelium from the crown 3. May arise due to accumulation of inflammatory exudate from primary tooth/ mainly mandibular

Dentigerous Cyst (Follicular Cyst)

Clinical features Most common with 3rd molars, maxillary canines and mandibular premolars

supernumerary teeth Odontomes

Asymptomatic unless

Large..bone expansion Infected.pain

Dentigerous cyst
Radiographic Features
well circumscribed, corticated border usually unilocular NOT DIAGNOSTIC Odontogenic keratocyst Unicystic ameloblastoma

Dentigerous cyst
Microscopic Features - nonkeratinized stratified squamous epithelial lining - may have occasional sebaceous or mucous cell metaplasia - thick fibrous connective tissue wall - epithelial rests - inflammation +/-

Dentigerous Cyst (Follicular Cyst)

Microscopic features

Dentigerous Cyst
Treatment and Prognosis Enucleation and removal of the affected tooth Little tendency to recur when completely removed

Why should the dentigerous cyst be removed?

Can cause extensive bone destruction Resorption of adjacent roots Displacement of teeth Neoplastic transformation:
Ameloblastoma Squamous cell carcinoma Central mucoepidermoid carcinoma

Neoplastic transformation in dentigerous cyst

Neoplastic transformation in dentigerous cyst

Eruption Cyst

Soft tissue analogue of the dentigerous cyst Soft, translucent swelling in the mucosa Relatively common in children No treatment is necessary

Eruption Cyst

Color Atlas of Clinical Oral pathology Neville, Damm and White, 2nd edition

Eruption Cyst

Color Atlas of Clinical Oral pathology Neville, Damm and White, 2nd edition

Questions?